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Pinon M, Kamath BM. What's new in pediatric genetic cholestatic liver disease: advances in etiology, diagnostics and therapeutic approaches. Curr Opin Pediatr 2024:00008480-990000000-00198. [PMID: 38957097 DOI: 10.1097/mop.0000000000001380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To highlight recent advances in pediatric cholestatic liver disease, including promising novel prognostic markers and new therapies. FINDINGS Identification of additional genetic variants associated with progressive familial intrahepatic cholestasis (PFIC) phenotype and new genetic cholangiopathies, with an emerging role of ciliopathy genes. Genotype severity predicts outcomes in bile salt export pump (BSEP) deficiency, and post-biliary diversion serum bile acid levels significantly affect native liver survival in BSEP and progressive familial intrahepatic cholestasis type 1 (FIC1 deficiency) patients. Heterozygous variants in the MDR3 gene have been associated with various cholestatic liver disease phenotypes in adults. Ileal bile acid transporter (IBAT) inhibitors, approved for pruritus in PFIC and Alagille Syndrome (ALGS), have been associated with improved long-term quality of life and event-free survival. SUMMARY Next-generation sequencing (NGS) technologies have revolutionized diagnostic approaches, while discovery of new intracellular signaling pathways show promise in identifying therapeutic targets and personalized strategies. Bile acids may play a significant role in hepatic damage progression, suggesting their monitoring could guide cholestatic liver disease management. IBAT inhibitors should be incorporated early into routine management algorithms for pruritus. Data are emerging as to whether IBAT inhibitors are impacting disease biology and modifying the natural history of the cholestasis.
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Affiliation(s)
- Michele Pinon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Vasudevan AK, Shanmugam N, Rammohan A, Valamparampil JJ, Rinaldhy K, Menon J, Thambithurai R, Namasivayam S, Kaliamoorthy I, Rela M. Outcomes of pediatric liver transplantation for progressive familial intrahepatic cholestasis. Pediatr Transplant 2023; 27:e14600. [PMID: 37675889 DOI: 10.1111/petr.14600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/05/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis (PFIC) is a heterogenous group of inherited hepatocellular disorders and the clinical aspects, role of liver transplantation (LT), and its outcomes remain largely unelucidated. We present our data of LT for each type of PFIC and compare their early, and long-term outcomes, highlighting their individual differences and management strategies. METHODS Prospectively collected data over a decade (2011-2022) of children with PFIC who underwent LT was analyzed. The groups (PFIC 1-4) were compared with regard to early and long-term outcomes including attainment of catch-up growth. RESULTS Of 60 children with PFIC who underwent LT, 13, 11, 31 & 5 were of PFIC 1, 2, 3 & 4, respectively. There were no significant differences in gender, PELD scores, BMI, type of grafts, cold and warm ischemia times, intraoperative blood loss, and morbidity among the groups. Post-LT chronic diarrhea was observed in 6 (46.1%) children with PFIC-I, and of them, 3 (23%) developed graft steatohepatitis. Three of these children underwent total internal biliary diversion (TIBD) and on 1-year follow-up, their graft steatosis resolved and they attained catch-up growth. Catch-up growth was significantly poorer in the PFIC1 group (44.4% vs. 88%, 90%, 100% p < .001). Overall 1- and 5-year patient survival of the four PFIC groups (1-4) were 69.2%, 81.8%, 96.8%, 100% & 69.2%, 81.8%, 96.8%, 100%, respectively. CONCLUSION Ours is the largest to-date series of LT for PFIC illustrating their short- and long-term outcomes. While the results for the whole cohort were excellent, those after LT for PFIC1 was relatively poorer as reflected by catch-up growth, graft steatosis, and post-LT diarrhea, which can be optimized by the addition of TIBD during LT.
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Affiliation(s)
- Anu K Vasudevan
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Naresh Shanmugam
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Joseph J Valamparampil
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Kshetra Rinaldhy
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Jagadeesh Menon
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Ravikumar Thambithurai
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Saravanapandian Namasivayam
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Ilankumaran Kaliamoorthy
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
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Kavallar AM, Mayerhofer C, Aldrian D, Okamoto T, Müller T, Vogel GF. Management and outcomes after liver transplantation for progressive familial intrahepatic cholestasis: A systematic review and meta-analysis. Hepatol Commun 2023; 7:e0286. [PMID: 37756114 PMCID: PMC10531212 DOI: 10.1097/hc9.0000000000000286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/17/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis (PFIC) is a heterogeneous rare congenital cholestatic liver disease. Disease progression might necessitate liver transplantation (LT). The aim of this study was to describe the outcome of PFIC1-4 patients after LT. METHODS Electronic databases were searched to identify studies on PFIC and LT. Patients were categorized according to PFIC type, genotype, graft type, age at LT, time of follow-up, and complications and treatment during follow-up. RESULTS Seventy-nine studies with 507 patients met inclusion criteria; most patients were classified as PFIC1-3. The median age at LT was 50 months. The overall 5-year patient survival was 98.5%. PFIC1 patients with diarrhea after LT were at significant risk of developing graft steatosis ( p < 0.0001). Meta-analysis showed an efficacy of 100% [95% CI: 73.9%-100%] for surgical biliary diversion to ameliorate steatosis and 94.9% [95% CI: 53.7%-100%] to improve diarrhea (n = 8). PFIC2 patients with bile salt export pump (BSEP)2 or BSEP3-genotype were at significant risk of developing antibody-induced BSEP deficiency (AIBD) ( p < 0.0001), which was reported in 16.2% of patients at a median of 36.5 months after LT. Meta-analysis showed an efficacy of 81.1% [95% CI: 47.5%-100%] for rituximab-based treatment regimens to improve AIBD (n = 18). HCC was detected in 3.6% of PFIC2 and 13.8% of PFIC4 patients at LT. CONCLUSIONS Fifty percent of PFIC1 patients develop diarrhea and steatosis after LT. Biliary diversion can protect the graft from injury. PFIC2 patients with BSEP2 and BSEP3 genotypes are at significant risk of developing AIBD, and rituximab-based treatment regimens effectively improve AIBD. PFIC3 patients have no PFIC-specific complications following LT.
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Affiliation(s)
- Anna Maria Kavallar
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Mayerhofer
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Denise Aldrian
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Tatsuya Okamoto
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Thomas Müller
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Friedrich Vogel
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Cell Biology, Medical University of Innsbruck, Innsbruck, Austria
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Kavallar AM, Messner F, Scheidl S, Oberhuber R, Schneeberger S, Aldrian D, Berchtold V, Sanal M, Entenmann A, Straub S, Gasser A, Janecke AR, Müller T, Vogel GF. Internal Ileal Diversion as Treatment for Progressive Familial Intrahepatic Cholestasis Type 1-Associated Graft Inflammation and Steatosis after Liver Transplantation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121964. [PMID: 36553407 PMCID: PMC9777440 DOI: 10.3390/children9121964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Progressive Familial Intrahepatic cholestasis type I (PFIC1) is a rare congenital hepatopathy causing cholestasis with progressive liver disease. Surgical interruption of the enterohepatic circulation, e.g., surgical biliary diversion (SBD) can slow down development of liver cirrhosis. Eventually, end stage liver disease necessitates liver transplantation (LT). PFIC1 patients might develop diarrhea, graft steatosis and inflammation after LT. SBD after LT was shown to be effective in the alleviation of liver steatosis and graft injury. CASE REPORT Three PFIC1 patients received LT at the ages of two, two and a half and five years. Shortly after LT diarrhea and graft steatosis was recognized, SBD to the terminal ileum was opted to prevent risk for ascending cholangitis. After SBD, inflammation and steatosis was found to be reduced to resolved, as seen by liver biochemistry and ultrasounds. Diarrhea was reported unchanged. CONCLUSION We present three PFIC1 cases for whom SBD to the terminal ileum successfully helped to resolve graft inflammation and steatosis.
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Affiliation(s)
- Anna M. Kavallar
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Denise Aldrian
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Valeria Berchtold
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Murat Sanal
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Simon Straub
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Anna Gasser
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Andreas R. Janecke
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Institute of Human Genetics, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Thomas Müller
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Georg F. Vogel
- Department of Paediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Institute of Cell Biology, Biocenter, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-(0)-512-504-23501; Fax: +43-(0)-512-504-23491
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Bedoyan SM, Lovell OT, Horslen SP, Squires JE. Odevixibat: a promising new treatment for progressive familial intrahepatic cholestasis. Expert Opin Pharmacother 2022; 23:1771-1779. [PMID: 36278881 PMCID: PMC10074157 DOI: 10.1080/14656566.2022.2140040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Progressive familial intrahepatic cholestasis (PFIC) refers to a group of heterogeneous, mostly autosomal recessive disorders resulting from the inability to properly form and excrete bile from hepatocytes. The resulting shared phenotype is one of hepatocellular cholestasis. Clinical management targeting refractory itch and surgical interventions to interrupt the enterohepatic circulation are often pursued with variable efficacy. Recent development of the family of IBAT inhibitor therapeutics has introduced a novel tool in the armamentarium for the treatment of PFIC. AREAS COVERED Data from Phase 3 and 3 clinical trials were reviewed. The primary endpoints in most studies included effect on pruritus, serum bile acid levels, and quality of life metrics, with the duration of the study ranging between 24 and 72 weeks. Most common adverse events included diarrhea, vomiting, and elevation in transaminases. EXPERT OPINION IBAT inhibition with therapeutics such as odevibixat have shown that it is well-tolerated and efficacious in mitigating itch and reducing serum bile acid levels. While the few early published trials with odevixibat have shown good efficacy, what remains to be seen is long-term, sustainable improvement and if or how these medications will supplement or replace the current medical and surgical therapies available for managing PFIC disorders.
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Affiliation(s)
- Sarah M. Bedoyan
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Olya T. Lovell
- Department of Pharmacy, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Simon P. Horslen
- Division of Gastroenterology and Hepatology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James E. Squires
- Division of Gastroenterology and Hepatology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
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